Provider Demographics
NPI:1376938472
Name:HENNEMAN, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HENNEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WOODRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1934
Mailing Address - Country:US
Mailing Address - Phone:413-454-4437
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298560207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine